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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600928
Report Date: 01/17/2023
Date Signed: 01/17/2023 11:20:57 AM


Document Has Been Signed on 01/17/2023 11:20 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:LAFAYETTE HEIGHTS RES. CAREFACILITY NUMBER:
075600928
ADMINISTRATOR:MOGADAM, JOANNEFACILITY TYPE:
740
ADDRESS:34 CAMINO JUSTINTELEPHONE:
(925) 979-1200
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:6CENSUS: 6DATE:
01/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Joanne Mogadam, AdministratorTIME COMPLETED:
11:30 AM
NARRATIVE
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On 1/17/2023 starting at 9:15 am, Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator and disclosed the purpose of the visit.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. There is one central entry point for universal screening for staff, residents and visitors. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has Infection Control Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff and visitors.

THE FOLLOWING DEFICIENCIES WERE OBSERVED:
· At 9:50 a.m., LPA observed 3 items of expired food in the refrigerator and freezer: An opened bag of Ground Beef was used by 1/7/23, an unopened Soursop Neater was expired 11/7/22, an unopened pack of White Turkey was expired 12/27/22.
· At 10:30 a.m., LPA observed 3 dementia residents didn't have updated annual physician's reports on file.

The above deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date and/or any repeat deficiencies within a 12-month period may result in additional Civil Penalties.

Exit interview conducted with Administrator. LIC809D, Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


Document Has Been Signed on 01/17/2023 11:20 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: LAFAYETTE HEIGHTS RES. CARE
FACILITY NUMBER: 075600928

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above, LPA observed 3 items were expired, ground beef was used by 1/7/23, Soursop Neater was 11/7/22, and white turkey was 12/27/22 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2023
Plan of Correction
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Administrator agrees to retrain staff to manage food including but not limited to label and check expiration dates, and submit a in-service training to CCL by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 01/17/2023 11:20 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: LAFAYETTE HEIGHTS RES. CARE
FACILITY NUMBER: 075600928

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 3 out of 6 residents who have dementia didn't have updated annual physician's report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2023
Plan of Correction
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Administrator agrees to update residents' physician's report (LIC602A), and submit copies to CCL by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5